Cost-effectiveness of abdominal aortic aneurysm repair: A systematic review

Jonk, Yvonne; Kane, Robert L; Lederle, Frank A.; MacDonald, Roderick; Cutting, Andrea; Wilt, Timothy J

doi:10.1017/s0266462307070316

Cited by 29 publications

(24 citation statements)

References 38 publications

(80 reference statements)

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“…All three Markov modeling studies published to date have also predicted higher lifetime costs associated with EVAR. 364 In the most recent analysis using data incorporated from the EVAR-1 and DREAM trials, a cost effectiveness ratio of £110,000/QALY was calculated for a 70-year-old man undergoing EVAR for a 5.5 cm AAA as compared with OSR; a result incompatible with the notion of overall costeffectiveness. In this analysis, EVAR consistently produced an incremental cost-benefit ratio of Ͼ £30,000/QALY over a range of alternative cost and outcome scenarios.…”

Section: Cost and Economic Considerations In Aneurysm Repairmentioning

confidence: 99%

The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines

Chaikof

Brewster

Dalman

et al. 2009

Journal of Vascular Surgery

625

529

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DEFINITION OF THE PROBLEM Purpose of these guidelinesThe Clinical Practice Council of the Society for Vascular Surgery charged a writing committee with the task of updating practice guidelines, initally published in 2003, for surgeons and physicians who are involved in the preoperative, operative, and postoperative care of patients with abdominal aortic aneurysms (AAA). 1 This document provides recommendations for evaluating the patient, including risk of aneurysm rupture and associated medical co-morbidities, guidelines for selecting surgical or endovascular intervention, intraoperative strategies, perioperative care, long-term follow-up, and treatment of late complications.Decision making related to the care of patients with AAA is complex. Aneurysms present with varying risks of rupture and patient specific factors influence anticipated life expectancy, operative risk, and the need to intervene. Careful attention to the choice of operative strategy, as influenced by anatomic features of the AAA, along with optimal treatment of medical co-morbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative patient surveillance and timely intervention in the case of a late complication is necessary to minimize subsequent aneurysm-related death or morbidity. All of these clinical decisions are determined in an environment where cost-effectiveness will ultimately dictate the ability to provide optimal care to the largest possible segment of the population. Currently available clinical data sets have been reviewed in formulating these recommendations. However, an important goal of this document is to clearly identify those areas where further clinical research is necessary. Methodology and evidenceA comprehensive review of the available clinical evidence in the literature was conducted in order to generate a concise set of recommendations. The strength of any given recommendation and the quality of evidence was scored based on the GRADE system (Table I). 2 When the benefits of an intervention outweighed its risks, or, alternatively, risks outweighed benefits, a strong recommendation was noted. However, if benefits and risks were less certain, either because of low quality evidence or because high quality evidence suggests benefits and risks are closely balanced, a weak recommendation was recorded. The quality of evidence that formed the basis of these recommendations was scored as high, moderate, or low. Not all randomized controlled trials are alike and limitations may compromise the quality of their evidence. In addition, if there is a large magnitude of effect, the quality of evidence derived from observational studies may be high. Thus, quality of evidence was scored as high when additional research is considered very unlikely to change confidence in the estimate of effect; moderate when further research is likely to have an important impact in the estimate of effect; or low when further research is very likely to change the estimate of the effect.

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Section: Cost and Economic Considerations In Aneurysm Repairmentioning

confidence: 99%

The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines

Chaikof

Brewster

Dalman

et al. 2009

Journal of Vascular Surgery

625

529

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“…Pilot data were collected to assess the availability and influence of costing data identified in a systematic review of the cost-effectiveness of AAA repair. 87 After review of initial pilot data, a standard proforma (see Appendix 9) was designed to capture preoperative, perioperative and postoperative appointments, scans, and procedures clinically associated with the AAA repair. Data were collected from a mix of district general 17.8%) in the two populations.…”

Section: Vascular Governance North West Programmementioning

confidence: 99%

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Grant

Sperrin

Carlson

et al. 2015

Health Technology Assessment

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BackgroundAbdominal aortic aneurysm (AAA) repair aims to prevent premature death from AAA rupture. Elective repair is currently recommended when AAA diameter reaches 5.5 cm (men) and 5.0 cm (women). Applying population-based indications may not be appropriate for individual patient decisions, as the optimal indication is likely to differ between patients based on age and comorbidities.ObjectiveTo develop an Aneurysm Repair Decision Aid (ARDA) to indicate when elective AAA repair optimises survival for individual patients and to assess the cost-effectiveness and associated uncertainty of elective repair at the aneurysm diameter recommended by the ARDA compared with current practice.Data sourcesThe UK Vascular Governance North West and National Vascular Database provided individual patient data to develop predictive models for perioperative mortality and survival. Data from published literature were used to model AAA growth and risk of rupture. The cost-effectiveness analysis used data from published literature and from local and national databases.MethodsA combination of systematic review methods and clinical registries were used to provide data to populate models and inform the structure of the ARDA. Discrete event simulation (DES) was used to model the patient journey from diagnosis to death and synthesised data were used to estimate patient outcomes and costs for elective repair at alternative aneurysm diameters. Eight patient clinical scenarios (vignettes) were used as exemplars. The DES structure was validated by clinical and statistical experts. The economic evaluation estimated costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the NHS, social care provider and patient perspective over a lifetime horizon. Cost-effectiveness acceptability analyses and probabilistic sensitivity analyses explored uncertainty in the data and the value for money of ARDA-based decisions. The ARDA outcome measures include perioperative mortality risk, annual risk of rupture, 1-, 5- and 10-year survival, postoperative long-term survival, median life expectancy and predicted time to current threshold for aneurysm repair. The primary economic measure was the ICER using the QALY as the measure of health benefit.ResultsThe analysis demonstrated it is feasible to build and run a complex clinical decision aid using DES. The model results support current guidelines for most vignettes but suggest that earlier repair may be effective in younger, fitter patients and ongoing surveillance may be effective in elderly patients with comorbidities. The model adds information to support decisions for patients with aneurysms outside current indications. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty.LimitationsLack of high-quality long-term data to populate all sections of the model meant that there is high uncertainty about the long-term clinical and economic consequences of repair. Modelling assumptions were necessary and the developed survival models require external validation.ConclusionsThe ARDA provides detailed information on the potential consequences of AAA repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. Further research is required to reduce uncertainty about key data, including reintervention following AAA repair, and assess the acceptability and feasibility of the ARDA for use in routine clinical practice.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…3,4 AAA rupture has a mortality rate of 90%, 5 and death from ruptured AAAs is the 10th leading cause of death in men above the age of 65. 6 An intraluminal thrombus (ILT) is found in nearly all AAAs with a diameter large enough to indicate risk of rupture.…”

mentioning

confidence: 99%

Failure properties of intraluminal thrombus in abdominal aortic aneurysm under static and pulsating mechanical loads

Gasser

Görgülü

Folkesson

et al. 2008

Journal of Vascular Surgery

158

147

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ILT tissue is vulnerable against fatigue failure and shows significant decreasing strength with respect to the number of load cycles. Hence, after a reasonable time of pulsating loading ILT's strength is far below its ultimate strength, and when compared with stress predictions from finite element (FE) studies, this indicates the likelihood of fatigue failure in vivo. Failure within the ILT could propagate towards the weakened vessel wall behind it and could initialize AAA failure thereafter.

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Cost-effectiveness of abdominal aortic aneurysm repair: A systematic review

Abstract: Although conclusions regarding the cost-effectiveness of AAA treatment options are time dependent and vary by institutional perspective, from a societal perspective, endovascular repair is not currently cost-effective for patients with large AAA regardless of medical fitness.

Cited by 29 publications

References 38 publications

The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines

The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Failure properties of intraluminal thrombus in abdominal aortic aneurysm under static and pulsating mechanical loads

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